Ethical and legal issues in do-not-resuscitate decision-making

Ethical Decision

'Not to Resuscitate' is indeed a difficult decision that has to be made by the patient, when he or she is in good health, or the guardians of the patient. However, according to the law and ethical code of conduct, the medical practitioner, or whoever is in charge of the health care of a patient in a hospital setting, should always inform the patient about the whole procedure (L., 2008). There are certain indications when resuscitation needs to be performed on the patients, meanwhile there are also some contradictions where it should not be performed on the patient. Nonetheless, the final decision lies with the patient or with family. The indications of this decision include a case in which resuscitation would be of any help to save the life of the patient. For example, if the patient is dying and who has been given all sorts of treatment but death has now become imminent and there is no treatment that will save the patient, then resuscitation is normally not performed on the patient. On the other hand, if there is any comorbidity because of resuscitation would be of no help then a request for 'Not to Resuscitate' is given. Such comorbidities include severe pneumonia, significant acute renal failure, hypotension with heart failure and metastatic malignant disease. In such cases, the patient or the family of the patient are normally requested to sign an NTR because it could be stressful for a patient as well as for the family. In this case, Mrs. Lily was not terminally ill and neither did she have comorbidities that have been mentioned above. On top of that, neither was Mrs. Lily nor the family was asked before putting a NTR note on the medical documents of Mrs. Lily. A very strict legal action could be taken on this action of the medical staff.

Professional Communication

Most of the doctors and medical staff tend to underestimate the fact that most of the people who know that they are going to die are actually very keen to know about their death. Therefore, doctors and the medical staff should always make sure that the patient is informed about the decision that is being made about the resuscitation procedure. As mentioned earlier, the decision for resuscitation should always lie with the patient. The patient should be informed about the whole procedure clearly and then his consent should be taken about the matter. In cases where consultants think that the life of the patient could be saved by performing CPR (cardiopulmonary resuscitation) but the patient is not being compliant and does not want the procedure to be performed on him or her, then the doctor should counsel the patient. This requires the doctor and the medical staff to show empathy for the patient and to consider them in the place of the patient. Moreover, it is important for the doctor to build a reputation with the patient. These are one of the times when the doctors have to act very professional at a humanitarian level. They have to explain the procedure in a way that does not make the patient scared of what is going to happen to him or her.

It should always be remembered that in a clinical set up, the consultant should be asked to do the job of asking the patient whether or not him or her would want to get resuscitate if the need be. Junior doctors or registrars for that matter should be given the authority to get an NTR letter signed by the patient of the family. However, the junior staff can write the letter and then get it rectified by the senior consultant.

Another thing that is important pertaining to the professional communication is that not just the patient, but also the relatives and care givers of the patient should be taken in confidence. This is especially important if the patient is not the in the state to give his or her own decision. Likewise, the whole protocol of CPR should be explained to the family of the patient and ask them if they want the procedure to be performed on the patient. For example, there is a case where the doctors think that CPR would not save the life of the patient but the family insists on doing CPR on the patient since they believe that it 'might' just save their family members, then it is duty of the doctor to counsel the relatives by explaining why the procedure would not work on them. If the relatives still insist that the procedure should be performed then the doctors should go for it.

In this case, however, the family was not informed about the procedure or its indication and neither was Mrs. Lily. It was the right of the patient and that of the family to know that the doctors think that NTR decision should be taken for her. Professional communication was not exercised in this case and this could have serious implications in the future as Mrs. Lily and her family can sue the doctors and the medical staff.

Requirements of Consent

Consent is of utmost importance in the medical setup and clinical practice. Doctors are told to take consent from the patients even if they are doing the slightest of procedures on them or even when they have to take their history. It has been made mandatory for the doctors and the nurses to take consent from the patients in their ethical code of conduct. Whosoever does not take consent from the patient before taking their history, advising some medication or doing any sort of procedure on them, does in fact violates the law. It should be remembered that there is not a single kind of consent but many. Therefore, the doctors must see what sort of consent is applicable in a specific situation and then act accordingly (J., 2005).

First of all, the doctors and nurses should remember that the consent should always be in form of a typed paper. However, most of the times because of common practice and to save time many consultants just the verbal consent. Either way, consent should be proper and the doctor must only proceed if the patient agrees (Nandimath, 2009).

The kind of consent that the doctors are required to take from the patient in most of the cases is the informed consent. In this type of consent, the doctors tell the patient everything about the procedure or examination that they are about to perform on the patient (Zafar et. al, 2011). The doctors are required to tell the patient what he will be doing as a part of the treatment and the procedure that he is about to perform. The doctor is required to tell the patient why he or she is doing what he or she is doing and what are the possible outcomes of the examination or the procedure. Moreover, the doctors also have to tell the patient about the potential complications of the procedure that the doctor will be performing on the patient. If the patient agrees to whatever the doctors have told him or her, only then the doctor should proceed with the treatment. Same is the case with CPR or NRT. The patient should be told why there might arise a need where the doctors would have to perform a CPR on the patient. Moreover, the doctors also need to tell the patient why they would make a decision of NRT.

Then the second kind of consent is the blanket consent. This is the kind of consent in which the doctors tell some part of the procedure to the patient and withholds some of the information in good will. This is mostly done in the cases where the patient is not agreeing to a specific procedure but the doctors think that it is necessary to perform it on them, for example if the life of the patient is at risk (O'Neill, 2003).

Another kind of consent that would be talked about in this paper is the implied consent. This means that when a person walks in the emergency of a clinic or a hospital, he has come there because of some serious problem which he wants to get treated. In this case, the doctor is allowed to start the treatment without taking consent of the patient since it is implied. However, when a life changing decision has to be made about the patient while he is being treated in the emergency then it is important for the doctors to take consent from the patient.

Apart from the types of consent that have been mentioned above, there are many other sorts of consent that have been mentioned in the Laws of Clinical Practice and the doctors should always refer to the code of conduct that has been devised for them. It should be remembered that if the patient has given consent then the burden of negligence lies with the patient (in case any negligence takes place during any procedure that has adverse effects on the health of the patient). This implies that in case of any negligence, the patient will have to prove that negligence on the part of the doctor took place. This is only possible when the doctor had taken consent from the patient. On the other hand, if the doctors do not take consent from the patient then the burden of proof lies with the doctor. This means that the doctor will have to prove that he was not negligent while performing the procedure.

The doctors should take consent from the family of the patient if the patient is not in the state to give consent him or herself. In any case, however, the doctors are required to take consent from the patient or the family (Miler and Wertheimer, 2009). In this case, Mrs. Lily was not told that a decision for an NTR was taken for her. The consent for this decision was not taken from her family either. Therefore, this clearly means that the code of conduct was violated by the doctors.

Use of Health Resources

The use of health resources that are involved with a decision of NTR are only those of the stay at the hospital. It should be noted that most of the people about whom the patient, family or the consultant has to take an NTR decision are admitted to the ICU. The amount of health resources that are spent in the ICU are more than in any ward or department of the hospital. Therefore, the patient and the family should be informed about the charges and use of health resources regarding NTR as a part of the informed consent taken from the patient and/or the family.

Conclusion

Basically, from this case one has many lessons to learn pertaining to the medical practice or as a professional nurse. It should always be remembered that when the patient is in the state of giving the consent, the consent should always be taken by the patient (Salinset, al, 2010). The whole procedure should be explained to the patient and in the end the wishes of the patient should be honored. In this case Mrs. Lily had absolutely no idea why a decision for NTR was added to her medical notes. Even if the doctors think that it is for her own good, she should have been told about it from before.

The next main thing that we can infer from this paper is that making a decision for NTR is not an easy one. The doctors should involve the patient and the family of the patient before taking any such decision for the patient.

Bibliography:

Miller, Franklin and Wertheimer, Alan (2009). "The Ethics of Consent: Theory and Practice." Oxford Scholarship Online, Print.

Nandimath, Omaprakash V. (2009). Consent and medical treatment: The legal paradigm in India. Indian J. Urol. 25(3): 343-347.

O' Neill, O (2003).Some limits of informed consent. J Med Ethics.

Salins, Naveen S.; Pai, Sachin G.; Vidyasagar, MS; Sobhana, Manikkath (2010).Ethics and Medico Legal Aspects of "Not for Resuscitation." Indian J. Palliat Care.

Soar, J.; Mancini, ME., Bhanji, F., Billi, JE., Dennett, J., Finn, J., Ma MHM, Perkins, GD.,

Rodgers, DL., Hazinski, MF., Jacobs, I., Morley, P.T. (2010).Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010;81:e288e330.

Skene, L. (2008). Law and Medical Practice, Rights, duties, Claims and Defenses. 3rd edition, Australia, LexisNexus.

Tibballs, J. (2005). Legal liabilities for assistance and lack of assistance rendered by Good Samaritans, Volunteers and their organizations.Insurance Law Journal 2005.

Zafar, Shamsa; Malik, Rizwan H.; Sami, Ahmed N.; Avais, Ayesha R.; Avais, Ahsan and Malik, Fatima N. (2011). The Awareness of 'Informed Consent', Among Medical Students and the Current Consent Practices at a Tertiary Care Hospital.Ann. Pak. Inst. Med. Sci.